Treatment intensification in patients with type 2 diabetes who failed metformin monotherapy

AIM

To evaluate the time to and factors associated with treatment intensification in patients with type 2 diabetes who failed metformin monotherapy.

METHODS

In a retrospective analysis using a large US electronic medical record database, eligible patients included those with type 2 diabetes and an HbA(1c) of ≥7.0% or at least two fasting blood glucose levels of ≥126 mg/dl while on metformin monotherapy for at least 6 months within the period of 1 January 1997 to 31 December 2008. Time to treatment intensification was calculated as the time between index date (date on which HbA(1c) ≥ 7% after metformin monotherapy for at least 6 months) and first prescription for additional antihyperglycaemic agent during follow-up period. All patients were required to have data for at least 12 months prior to and following the index date. A Cox proportional hazards model was employed to determine patient baseline characteristics associated with time to treatment intensification.

RESULTS

Of the 12 566 patients identified, mean age at index date was 63 years and 51% were female. Mean index HbA(1c) was 8.0% overall, with 66, 19 and 15% of patients having an index HbA(1c) of 7 to <8%, 8 to <9% and ≥9%, respectively. Median time to treatment intensification was 14.0 months overall and 19.0, 8.7 and 4.5 months for patients with index HbA(1c) of 7 to <8%, 8 to <9% and ≥9%, respectively. Factors associated with treatment intensification included higher index HbA(1c) , younger age, higher Charlson co-morbidity index, metformin daily dose ≥ 1500 mg and later index date (all p < 0.05).

CONCLUSIONS

In US clinical practice, median time to receive additional antihyperglycaemic medication is more than 1 year for patients with type 2 diabetes who failed metformin monotherapy.

Short range ordering in the modified honeycomb lattice compound SrHo(2)O(4)

The low temperature behaviour of single crystalline SrHo(2)O(4) has been characterized by dc magnetic susceptibility, heat capacity, and neutron scattering experiments. Our results show that despite the lack of magnetic long-ranged ordering in the presence of strong antiferromagnetic correlations, SrHo(2)O(4) does not order down to 1.8 K. Elastic neutron scattering experiments show prominent magnetic diffuse scattering correlated with a broad feature in the dc susceptibility at T = 4 K, indicative of magnetic short-ranged ordering of the Ho(3) spins. Inelastic neutron scattering shows the presence of five crystal field levels up to 80 K in energy, in agreement with the integration of the magnetic specific heat component yielding Rln5 entropy release. The magnetic short-ranged ordering is fitted to a nearest neighbour interaction model with good agreement.

Spin liquid state in the S = 1/2 triangular lattice Ba3CuSb2O9

The synthesis and characterization of Ba3CuSb2O9, which has a layered array of Cu2+ spins in a triangular lattice, are reported. The magnetic susceptibility and neutron scattering experiments of this material show no magnetic ordering down to 0.2 K with a θ(CW) = -55  K. The magnetic specific heat reveals a T-linear dependence with a γ = 43.4  mJ  K(-2)  mol(-1) below 1.4 K. These observations suggest that Ba3CuSb2O9 is a new quantum spin liquid candidate with a S = 1/2 triangular lattice.

Strong impact of acute kidney injury on survival after liver transplantation

Acute kidney injury (AKI) is a major complication in orthotopic liver transplantation (OLT). In an evaluation of Acute Kidney Injury Network (AKIN) criteria in liver transplanted patients, we retrospectively analyzed the usefulness of these criteria to predict survival of 193 consecutive patients at a single center who underwent primary OLT for clinical parameters and peak AKI. Postoperative AKI according to AKIN occurred in 60.1% of the patients, namely, stages 1, 2, and 3 in 30%, 13% and 17.1% respectively. Using multivariate logistic regression, AKIN stage 1 and 2 AKI were independently associated with the pre-OLT Model for End-Stage Liver Disease (MELD) score and age, while stage 3 AKI was independently associated with MELD and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. The 28-day and 1-year mortality post-OLT of AKI patients were 15.5% and 25.9% respectively compared with 0% and 3.9% among non-AKI patients (P < .05 for both). The survival rates of non-AKI and stages 1, 2, and 3 AKI subjects were 96%, 85.5%, 84%, and 45.3%, respectively. Cox regression analysis showed independent risk factors for mortality during the first year after transplantation to include post-OLT AKI (12.1; P < .05), post-OLT infection (HR 4.7; P < .01), pre-OLT hypertension (HR 4.4; P < .01) hazard ratio [HR] and post-OLT APACHE II ≥10 (HR 3.6; P < .05). We concluded that AKI as defined by the AKIN criteria is a major complication of OLT linked to a poor outcomes. It remains to be evaluated whether aggressive perioperative therapy to prevent AKI can improve survival among OLT patients.

Mega-voltage versus kilo-voltage cone beam CT used in image guided radiation therapy: comparative study of microdosimetric properties

Mega-voltage computed tomography (MVCT) and kilo-voltage cone beam CT (CBCT) are routinely used in image-guided radiation therapy. In current practice, doses from MVCT and CBCT are reported with no correction for radiation quality. In this study, we compared microdosimetric properties as well as doses for MVCT and CBCT. Monte Carlo simulation codes BEAMnrc and DOSXYZnrc were used to simulate a Varian CBCT 125 kVp photon beam and primary electron spectra for CT sets of two patients. The revised Oak Ridge Electron transport Code (NOREC) was used to simulate electron tracks in liquid water. C++ code was developed to compute lineal energy in a sphere of 1 μm diameter. Dose-mean lineal energy-based quality factors were calculated for critical organs in-field. The estimated quality factor for CBCT is up to a factor of 1.3 times that of MV beams.

A predictive value of hyponatremia for poor outcome and cerebral infarction in high-grade aneurysmal subarachnoid haemorrhage patients

BACKGROUND

The clinical significance of hyponatremia has not been investigated in high-grade aneurysmal subarachnoid haemorrhage (aSAH) patients. Thus, we assessed the predictive value of hyponatremia for poor outcome or cerebral infarction in high grade patients (the World Federation of Neurological Surgeons Scale (WFNS) grade 4 or 5) after aSAH.

METHODS

Patients with WFNS grade 4 or 5 after aSAH were selected into this study between January 2005 and January 2008. In the same period, patients with WFNS grade 1, 2 or 3 after aSAH (low grade) were also chosen into this study. Hyponatremia was determined with serum sodium measurements obtained within 9 days after aSAH. Prognosis of patients was estimated with Glasgow Outcome Scale at 3 months. The relationship between hyponatremia and poor outcome and association of hyponatremia and cerebral infarction were analysed, respectively.

RESULTS

A total of 124 high-grade patients were included in this study. Of those, 78 patients developed hyponatremia. Hyponatremia developed in 32.3% of cases between days 1 and 3 after aSAH, and 30.6% developed hyponatremia after 3 days post-aSAH. Multivariable analysis revealed that hyponatremia was not correlated with poor outcome in high-grade aSAH patients. Furthermore, only late-onset hyponatremia was correlated with cerebral infarction in these patients. Meanwhile, there was no significant correlation between hyponatremia and poor outcome or cerebral infarction in 259 low-grade aSAH patients.

CONCLUSIONS

Hyponatremia does not predict poor outcome in all-grade aSAH patients. However, late-onset hyponatremia in high-grade aSAH patients is associated with cerebral infarction. Therefore, the appropriate management of hyponatremia could be beneficial in those patients.

Level crossings and zero-field splitting in the {Cr8}-cubane spin cluster studied using inelastic neutron scattering and magnetization

Inelastic neutron scattering (INS) in variable magnetic field and high-field magnetization measurements in the millikelvin temperature range were performed to gain insight into the low-energy magnetic excitation spectrum and the field-induced level crossings in the molecular spin cluster {Cr(8)}-cubane. These complementary techniques provide consistent estimates of the lowest level-crossing field. The overall features of the experimental data are explained using an isotropic Heisenberg model, based on three distinct exchange interactions linking the eight Cr(III) paramagnetic centers (spins s = 3/2), that is supplemented with a relatively large molecular magnetic anisotropy term for the lowest S = 1 multiplet. It is noted that the existence of the anisotropy is clearly evident from the magnetic field dependence of the excitations in the INS measurements, while the magnetization measurements are not sensitive to its effects.

Atypical teratoid/rhabdoid tumors in adult patients: CT and MR imaging features

Primary AT/RT is a rare highly malignant tumor of the CNS, usually occurring in children younger than 5 years of age. The objective of this study was to characterize the CT and MR imaging findings in a series of 5 adult patients with pathologically proved AT/RT. All 5 AT/RTs were supratentorial. In 2 patients who underwent nonenhanced CT, the tumors appeared isoattenuated, and 1 of the 2 tumors contained calcifications. Solid portions of the tumors on MR imaging were isointense on T1-weighted, T2-weighted, and FLAIR images, and 1 case showed restricted diffusion on DWI. The tumors also demonstrated a bandlike rim of strong enhancement surrounding a central cystic area on contrast-enhanced T1-weighted imaging. One tumor was associated with destruction of the calvaria. Although AT/RTs can have nonspecific findings, the tumors in our series were large and isointense on T1-weighted, T2-weighted, and FLAIR images with central necrosis and prominent rim enhancement.

Ferromagnetically coupled Shastry-Sutherland quantum spin singlets in (CuCl)LaNb₂O₇

A thorough crystal structure determination at very low temperature of (CuCl)LaNb₂O₇, originally proposed as a spin-1/2 square-lattice antiferromagnet, is reported thanks to the use of single-crystal x-ray diffraction and powder neutron diffraction. State-of-the-art calculations (maximum entropy method) reveal that (CuCl)LaNb₂O₇ is orthorhombic with Pbam symmetry. First-principles calculations demonstrate that the dominant magnetic interactions are antiferromagnetic between fourth nearest neighbors with a Cu-Cl-Cl-Cu exchange path, which lead to the formation of spin singlets. The two strongest interactions between the singlets are ferromagnetic, which makes (CuCl)LaNb₂O₇ the first system of ferromagnetically coupled Shastry-Sutherland quantum spin singlets.

From (pi,0) magnetic order to superconductivity with (pi,pi) magnetic resonance in Fe(1.02)Te(1-x)Se(x)

The iron chalcogenide Fe(1+y)(Te(1-x)Se(x)) is structurally the simplest of the Fe-based superconductors. Although the Fermi surface is similar to iron pnictides, the parent compound Fe(1+y)Te exhibits antiferromagnetic order with an in-plane magnetic wave vector (pi,0) (ref. 6). This contrasts the pnictide parent compounds where the magnetic order has an in-plane magnetic wave vector (pi,pi) that connects hole and electron parts of the Fermi surface. Despite these differences, both the pnictide and chalcogenide Fe superconductors exhibit a superconducting spin resonance around (pi,pi) (refs 9, 10, 11). A central question in this burgeoning field is therefore how (pi,pi) superconductivity can emerge from a (pi,0) magnetic instability. Here, we report that the magnetic soft mode evolving from the (pi,0)-type magnetic long-range order is associated with weak charge carrier localization. Bulk superconductivity occurs as magnetic correlations at (pi,0) are suppressed and the mode at (pi, pi) becomes dominant for x>0.29. Our results suggest a common magnetic origin for superconductivity in iron chalcogenide and pnictide superconductors.

Impact of concurrent macrovascular co-morbidities on healthcare utilization in patients with type 2 diabetes in Europe: a matched study

AIM

To examine and to quantify the impact of concurrent macrovascular co-morbidities (MVC) on healthcare resource utilization among patients with type 2 diabetes mellitus (T2DM) in Europe.

METHODS

This is a matched cohort study based on the Real-Life Effectiveness and Care Patterns of Diabetes Management study, a multicentre, observational study with retrospective medical chart reviews of T2DM patients in Spain, France, UK, Norway, Finland, Germany and Poland. Included patients were aged > or =30 years at time of diagnosis of T2DM who added a sulfonylurea or a PPARgamma agonist to failing metformin monotherapy (index date) and had concurrent MVC (cases). A control cohort with T2DM but without concurrent MVC was identified using 1:1 propensity score matching. Logit models were used to identify the relationship between concurrent MVC and the likelihood of emergency room admission, receiving medical/surgical procedures, and hospitalization during the study period after controlling for baseline demographics, clinical information and baseline treatment. Negative binomial models were used to predict the number of office visits and length of hospital stay per year attributable to the concurrent MVC.

RESULTS

Relative to controls, patients with MVC were significantly more likely to have emergency department admissions [odds ratio (OR) 2.69; 95% CI: 1.56-4.65], receiving medical/surgical procedures (OR 2.57; 95% CI: 1.56-4.21) and hospitalizations (OR 2.58; 95% CI: 1.64-4.07) after controlling for other predictors. Similarly, MVC were associated with 1.49 additional office visits per year (p = 0.036) and 0.32 days of hospital stay per year (p = 0.023).

CONCLUSIONS

Within a seven-country European sample, this study showed that T2DM patients with MVC were more likely to use healthcare resources compared with T2DM patients without MVC.

Nutrition support with glutamine dipeptide in patients undergoing liver transplantation

AIM

The effect of total parenteral nutrition (TPN) support supplemented with alanyl-glutamine (Ala-Gln) dipeptide was investigated in a randomized, controlled clinical trial.

METHODS

Sixty-five patients with the diagnosis of end-stage liver disease or hepatic cellular carcinoma admitted for orthotopic liver transplantation were randomly divided into 3 groups: diet group (n = 21), TPN group (n = 22), and Gln group (n = 22). Patients in the TPN and Gln groups received isocaloric and isonitrogenous TPN for 7 days. Venous heparin blood samples were obtained for assay on days 2 and 9 after surgery; we performed routine pathologic tests.

RESULTS

Compared with the results on day 9 in the TPN group, there was a significant increase in the prognostic nutrition index and in prealbumin among the Gln group. Aspartate aminotransferase improved significantly by Gln treatment compared with traditional TPN support (P < .05). The pathologic results also showed Gln supplementation to reduce hepatic cell injury. A significant decrease in postoperative hospital stay was observed in the Gln group.

CONCLUSIONS

Posttransplant TPN support greatly improved protein metabolism and nutritional state of patients. TPN with Ala-Gln helped to improve synthetic function and to reduce the injury to a transplanted liver.

Dynamic scaling in the susceptibility of the spin-1/2 kagome lattice antiferromagnet herbertsmithite

The spin-1/2 kagome lattice antiferromagnet herbertsmithite, ZnCu(3)(OH)(6)Cl(2), is a candidate material for a quantum spin liquid ground state. We show that the magnetic response of this material displays an unusual scaling relation in both the bulk ac susceptibility and the low energy dynamic susceptibility as measured by inelastic neutron scattering. The quantity chiT(alpha) with alpha approximately 0.66 can be expressed as a universal function of H/T or omega/T. This scaling is discussed in relation to similar behavior seen in systems influenced by disorder or by the proximity to a quantum critical point.

A role of Miz-1 in Gfi-1-mediated transcriptional repression of CDKN1A

Zinc-finger (ZF) transcriptional repressor Gfi-1 plays an important role in hematopoiesis and inner ear development, and also functions as an oncoprotein that cooperates with c-Myc in lymphomagenesis. Gfi-1 represses transcription by directly binding to conserved sequences in the promoters of its target genes. CDKN1A encoding p21^Cip1 has been identified as a Gfi-1 target gene and shown to contain Gfi-1 binding sites in the upstream promoter region. We show here that Gfi-1 represses CDKN1A in a manner that is independent of its DNA binding activity. Gfi-1 interacts with POZ-ZF transcription factor Miz-1, originally shown to be a c-Myc interacting partner, and via Miz-1 binds to CDKN1A core promoter. Interestingly, Gfi-1 and c-Myc, through Miz-1, form a ternary complex on the CDKN1A promoter, and act in collaboration to repress CDKN1A. Gfi-1 knockdown results in enhanced levels of p21^Cip1 and attenuated cell proliferation. Notably, similar to c-Myc, the expression of Gfi-1 is downregulated by TGFβ and the level of Gfi-1 influences the response of cell to the cytostatic effect of TGFβ. Our data reveal an important mechanism by which Gfi-1 regulates cell proliferation and may also have implications for understanding the role of Gfi-1 in lymphomagenesis.

Insight into the dicrotic notch in photoplethysmographic pulses from the finger tip of young adults

This study aims to investigate arterial stiffness in selected young adults by non-invasively determining the characteristics of the photoplethysmographic dicrotic notch. A total of 15 volunteers participated in this study, divided into four groups by age and gender. Contour analysis was applied to analyse the photoplethysmographic dicrotic notch, including time-related and height-related parameters. The height of reflected wave, mirrored by the notch relative amplitude (NRA), was found to be significantly larger in the older group compared to the younger group (p = 0.016). The timing of the reflected wave, measured by three parameters, i.e. notch index (NI), notch latency (NL) and peak-to-notch latency (PTNL), significantly increased in the female group compared to the male group (all p < 0.02). The results confirm that arterial stiffness occurs in young adults, and demonstrate that a difference of arterial stiffness exists between young male and female. This study indicates that examining the characteristic notch of the PPG pulse could help in identifying differences of vascular activities.

Bronchogenic and Esophageal Cyst With Laryngeal Malformations in a Thoroughbred Foal

This report documents an unusual case of congenital foregut cyst with dysphagia and stridor in a Thoroughbred foal. Histologically, the bilocular cyst, near the junction of larynx and trachea, had an epithelial lining of bronchogenic and esophageal origin. Concomitant malformation of the laryngeal muscles and cartilage resulted in a combination of anomalies that have not been reported in the human or veterinary literature.